Provider Demographics
NPI:1871667964
Name:WILLIAM BALOGH
Entity type:Organization
Organization Name:WILLIAM BALOGH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BURGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-272-2136
Mailing Address - Street 1:1135 BROADWAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3535
Mailing Address - Country:US
Mailing Address - Phone:253-272-2136
Mailing Address - Fax:253-272-6151
Practice Address - Street 1:1135 BROADWAY
Practice Address - Street 2:SUITE 101
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3535
Practice Address - Country:US
Practice Address - Phone:253-272-2136
Practice Address - Fax:253-272-6151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAO.D.00001030152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WABA3098OtherREGENCE
WAWA0042OtherNBN
WA2051209Medicaid
WA3908OtherDAVIS VISION
WABA3098OtherREGENCE